HumanaChoice Giveback H5216-116 (PPO)

by Humana

2027 Medicare Advantage plan available in New Jersey

Plan ID H5216-116-0

Additional coverage:

HearingVisionDental

Medicare Advantage PPO $0 premium

Monthly plan premium $0 / mo

Annual deductible $0 / yr

Max out-of-pocket · in-network $4,150 / yr

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Plan Overview

HumanaChoice Giveback H5216-116 (PPO) is a Medicare Advantage Plan Without Prescription Drugs, which is available in New Jersey and offered by the health insurance company Humana. This plan's network type is PPO, which determines the in-network doctors who accept the plan and whether a referral is needed.

Plan Name HumanaChoice Giveback H5216-116 (PPO)

Insurance Carrier Humana

Plan Type Medicare Advantage Plan Without Prescription Drugs

Network Type PPO

Cost Summary

HumanaChoice Giveback H5216-116 (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out-of-pocket cost sharing of $4,150. The most common costs people evaluate when choosing a plan are listed here; a full list of benefit costs is defined below.

Monthly Premium $0 / mo

Annual Deductible $0 / yr

Max Out-of-Pocket · in-network $4,150 / yr

Primary doctor visit $0 copay

Specialist visit $25 copay

ER visit $150 copay

Ambulance $325 copay

Additional Benefits and Coverage

HumanaChoice Giveback H5216-116 (PPO) is a Medicare Advantage plan which does not include Medicare Part D prescription drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. HumanaChoice Giveback H5216-116 (PPO) includes coverage for hearing, vision, dental.

Part D Prescription Drug Coverage No

Dental Yes

Vision Yes

Hearing Yes

Nationwide Coverage No

Other benefits

Fitness benefit Limited coverage

Over-the-counter drug benefits Limited coverage

In-home support services Not covered

Home & bathroom safety devices Not covered

Meals for short duration Limited coverage

Annual physical exams Limited coverage

Telehealth Limited coverage

Medical Benefits

Doctor Services

Primary doctor visit In-network: $0 copay
Out-of-network: 30% coinsurance

Specialist visit In-network: $25 copay
Out-of-network: 50% coinsurance

Tests, labs & imaging

Diagnostic tests & procedures In-network: $0-$175 copay
Out-of-network: $65 copay

Lab services In-network: $0 copay
Out-of-network: $65 copay

Diagnostic radiology services (like MRI) In-network: $0-$780 copay
Out-of-network: $0 copay

Outpatient x-rays In-network: $0-$145 copay
Out-of-network: $65 copay

Emergency care $150 copay

Urgent care $65 copay

Hospital Services

Inpatient hospital coverage In-network:
  Tier 1
  $495 per day for days 1-6
  $0 per day for days 7-90
  $0 per stay
Out-of-network:
  30% per stay

Outpatient hospital coverage In-network: $0-$850 copay
Out-of-network: $0 copay

Skilled nursing facility

Skilled nursing facility In-network:
  Tier 1
  $20 per day for days 1-20
  $221 per day for days 21-100
Out-of-network:
  30% per stay

Preventive services

Preventive services In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance In-network: $325 copay
Out-of-network: $325 copay

Therapy services

Occupational therapy visit In-network: $40 copay
Out-of-network: 50% coinsurance

Physical therapy & speech & language therapy visit In-network: $40 copay
Out-of-network: 50% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist In-network: $35 copay
Out-of-network: 30% coinsurance

Outpatient individual therapy with a psychiatrist In-network: $35 copay
Out-of-network: 30% coinsurance

Outpatient group therapy visit In-network: $35 copay
Out-of-network: 30% coinsurance

Outpatient individual therapy visit In-network: $35 copay
Out-of-network: 30% coinsurance

Opioid treatment services

Opioid treatment services Covered

Other services

Durable medical equipment (like wheelchairs & oxygen) In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Prosthetics (like braces, artificial limbs) In-network: 20% coinsurance
Out-of-network: 50% coinsurance

Diabetes supplies In-network: $0 copay
Out-of-network: 30%-50% coinsurance

Extra Benefits

Hearing

Hearing exam In-network: $0 copay
Out-of-network: 95% coinsurance

Fitting/evaluation In-network: $0 copay
Out-of-network: 95% coinsurance

Hearing aids - prescription In-network: $499-$725 copay
Out-of-network: 95% coinsurance

Hearing aids - over the counter In-network: $0 copay
Out-of-network: 95% coinsurance

Preventive dental

Oral exam In-network: $0 copay
Out-of-network: $0 copay

Cleaning In-network: $0 copay
Out-of-network: $0 copay

Fluoride treatment Not covered

Dental x-rays In-network: $0 copay
Out-of-network: $0 copay

Comprehensive dental

Restorative services In-network: $25 copay
Out-of-network: $25 copay

Endodontics Not covered

Periodontics In-network: $0 copay
Out-of-network: $0 copay

Prosthodontics, removable Not covered

Prosthodontics, fixed Not covered

Maxillofacial prosthetics Not covered

Implant services Not covered

Oral and maxillofacial surgery Not covered

Orthodontics Not covered

Adjunctive general services In-network: $0 copay
Out-of-network: $0 copay

Vision

Routine eye exam In-network: $0 copay
Out-of-network: $0 copay

Contact lenses In-network: $0 copay
Out-of-network: $0 copay

Eyeglasses (frames & lenses) In-network: $0 copay
Out-of-network: $0 copay

Eyeglass frames (only) Not covered

Eyeglass lenses (only) Not covered

Upgrades Not covered

Plan documents & tools

Plan details (carrier site)Provider directory Drug list (formulary)

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